IVRC Meeting – Patient Engagement in Health Care With Virtual Reality

360 Immersive Showcases the November 2018 IVRC Meeting in a Discussion of Virtual Reality and how the Technology Can Enhance Patient Experiences

Speaker 1:          Want to turn this over to Chris Colon from Blue Cross of Idaho who’s going to introduce our guest speaker reel and I know as you know, you’re so excited about Ar Vr community here and I don’t have the things that we’re doing just because they’re like we’ve been talking about for a couple of years and we have a speaker and I couldn’t be more excited about this one hour, so I’d like to introduce our. He is the CEO for a Stanford resident, has been a leader in the vr industry for over 20 years since it’s for education. However, he pulled on developing a vision, how been developing the vision for how vr can enhance in his early years of Vr. Howard was really fortunate to have the opportunity to join the vibrant research community and the human interface technology lab at the University of Washington right here in the Pacific Northwest Direction of Dr Tom Furness.

Speaker 1:          The lab was a high of exploration full of creative tinkerers pushing the boundary, dividing human, and she works as a graduate researcher. How are joined that labs education group led by Dr Whitfield when bill lead a rag tag team on the virtual reality, roving vehicle, cognex computers around Washington state, getting school children their first pace of Vr, and inspiring them to think about how it might be used in the future. Howard was excited about the discovery that we can break the window of the computer monitor and step inside, transferring the way or transforming the way people interact, not just with these boxes we call computers, but more importantly with the information and knowledge, etc. Coupled with his own thesis research, exploring virtual environments for teaching japanese language, how are began to focus on a mission, putting these technologies and approaches to work to recast teaching and learning in 1995, howard and ari hollander form firsthand to follow it means goals.

Speaker 1:          So really quiCk highlights and I’m going to turn it over to our firsthand was it featured how startup in 10 minute in 2014, where howard spoke on the topic. Vr games are so much more than a toy asserting that vr games are a new tool for personalized medicine that ships wellness. The patient’s hands, health consumers of power are going to demand innovations that help them stay well on there. Um, and we all agree not just to react to disease and they’re going to demand that these innovations in front of him. So I think we saw some of that out there today. Most roles, most recently, howard, his team published beyond pain relief response to the opioid crisis with dr shorr neiman medical director pain services at providence medical group where they are seeing 30 percent better pain control, 20 percent reduction in opioid use, and the significant reduction in patient care costs is project portfolio also includes immersive vr applications for therapy, ptsd, augmented reality, surgical training, mobile apps, and interactive museum exhibits. Howard is a frequent invited speaker at conferences on the vr games and how, and again, we are thrilled to have him talk with us today. Please join me.

Speaker 2:          You know more about me than my mother.

Speaker 3:          I am totally impressed you. You did an awful lot of research there. Dug up some, some great history which some of which I will talk about, but thank you so much. I’m really excited to be here. I do give a lot of talks in this kind of, in this is my favorite thing to do is to talk to people who really understand vr and, or have a lot of curiosity about it. Um, I want to talk about it, you know, I’m going to try to hit a bunch of different topics. I’m not bore you with a lot of statistics, but show you some of the data that we found from using vr. Um, talk a lot about design because I, at my heart, I didn’t get into this because I want to be an entrepreneur and schlep around and sell things. I got into it because I’m a designer and thank you for that.

Speaker 3:          I, I mean I started doing, um, education and all of that. So I want to talk about those things and talk about design and how I approach the design and thinking about it as a, some, uh, from a design thinking perspective. Anyway, I’m going to talk for, you know, probably I don’t know as long as I talk, but I do want this to be a conversation. So if you do have burning questions, um, you know, please feel free, but we’ll have tried to get some discussion at the end. Um, here’s what I want to talk about. So, uh, what does vr, why is it quote healthy? Uh, that was, uh, you know, why, why, what about it is good for us, uh, an overview of vr pain relief, a framework for how we think about vr therapy in terms of the mechanisms of action. And I would say that I hope that this, um, what we’ve learned from vr pain relief is it’s a great way to figure out how immersion and the phenomenon of vr works.

Speaker 3:          Uh, but I think this is very, very applicable to a lot of different areas, learning, health care, all sorts of different things. So I hope you’ll take it in that way. Uh, and then designing vr, a health experiences. Um, so what is vr that, as you mentioned, that is my real mother. My real mother could not have given you that, that rundown with my personal history. I will tell you. So this is back. I say this is back when I had a future. Um, this is when, uh, the human interface technology lab that is that crazy. We called it the pizza box. Um, this is a seven and a half pound helmet. Uh, it’s from a company called division, which is now, you know, they were hit by the media or isn’t went the way of the dinosaurs. So, um, yeah, this a seven and a half pound helmet.

Speaker 3:          Yeah. So we had this proJect called the virtual reality roving vehicle. Um, the vr rv. I love that term. Uh, we took machines out across the state of Washington, uh, and taught kids to build virtual worlds and catch sharks and in vr and do things like that and they’re wearing this helmet. So the first experience of vr was a lot like this and, and the, this kind of speaks to the, where all this, all this technology that we’re using came from was the military. So it was great for people with strong next. I’m a tom pernice, one of my mentors. So I don’t know how many of you know who tom is. Tom is like the father of vr, so he was doing this way back in the, so you know about ivan sutherland probably, and tom was doing it back then too in the military.

Speaker 3:          Uh, what’s interesting is that, um, so the, how did he discovered this idea of immersion? So they were projecting information on to the visors of fighter pilots and trying to teach them things, trying to tell them things like your flying upside down and stuff like that. Real important things. A just in time information. And what they discovered, what they invented was the heads up display. What they discovered was they started projecting video in there and then they started making the field of view bigger and bigger and bigger. And then there was this point where everything changed and that all of a sudden performance jumped up dramatically. And they’re like, whoa, what happened? So they discovered this idea of immersion and, and uh, what is it is essentially is that we stopped seeing it as a, as a thing that we’re looking at and we start seeing it as, or feeling like it’s a place that we are.

Speaker 3:          And that is kind of the underlying thing. The, the big under insight was that immersion enhanced human performance. Um, this is my, goto gender, my goto, my own definition of vr. It’s a computer generated experience that evokes the sensation. The experience is real, that can be visual, it can be haptic, it can be a lot of different things. Um, there’s a lot more, uh, you know, there’s a lot more academic, um, kinds of definitions out there. But I think that this one serves me well, at least I’m so when people think of vr in healthcare, they tend to think of this. They think they think of, you know, surgical simulators and things for doctors and all of that. And this stuff is awesome. It’s great. Um, but it doesn’t address our real big social problems. So in this, in the United States, uh, we spend 17 percent of our gdp, three, a $3,000,000,000,000 a year, and we get the worst outcomes in healthcare of, of any developed nation.

Speaker 3:          Why is that? We have a lot of this. We have a lot of great surgeons. The doctors are great. We’re in a fantastic health facility, but, but it’s clearly that, that something’s wrong in the system and I think it’s because there’s an overemphasis in our, in both our healthcare system and the way that we look at it and the things that we try to get from it. We see ourselves as consumers and vr transforms that into helping us be health producers and that’s kind of the underlying theory that we, we try to bring. So instead of, of giving people opioids, we have this kind of situation where people are activated postsurgery, they’re in a bed, they’re moving, they’re engaged, and we find that they use less drugs. It reduces cost and they have a actually better pain outcomes. Uh, so the work that we’ve done very briefly, we’ve done mental health, a lifestyle sort of health habits and physical health.

Speaker 3:          Um, I’m going to talk about some of these examples. So I’m just going to run on, um, uh, you know, our mission is to use technology to improve health by improving the patient experience. So we have done surgical, surgical simulators and tHings like that, but really we see, we see the big benefit in this whole technology really being on the patient of things. Um, and we designed for activation. We don’t design for distraction. We designed to Activate the patients and help them be healthier on their own. And tHat’s that idea of, of a health producers. So vr in this context, reducing pain, reducing drugs, reducing costs, those are the outcomes we’re seeing. And that’s, um, that’s really encouraging for all of us. Uh, just one slide about the pain problem. Everybody has heard about the pain epidemic. This is one statistic that kind of really shocked me.

Speaker 3:          Um, so this is the cdc, um, maybe you’re familiar with this, but what they found was that opioid prescriptions longer than five days, um, so if you’re taking drugs for more than five days, it significantly increased the likelihood of continued to opioid use one or three years later. So if you look at this graph along the bottom, this is the number of days of opioid prescriptions. And then, uh, the along the top is, uh, you know, along the side is the percentage of people who are using drugs a year or three years later. So there’s nothing magical about five days, but what we find is that, I mean, that’s significant. So one year a risk increases from six to 12 percent and the human cost is really what we’re, what we’re most concerned about and the social costs of having all those drugs in the environment.

Speaker 3:          So this finding motivates us. We’re, there’s an urgent need for non-drug pain relief alternatives and interventions at the right time can have a really dramatic effect. So if we can help people post surgery to not to be using drugs less than five days, there’s a good chance that we can keep them from sliding into a longterm use. Um, uh, I’ve got a couple of videos that I want to show. This is a story of lieutenant sam brown. He returned from Afghanistan, uh, with severe burns. He was in gq magazine, has been on television the bunch and he used snow world. So we built this application snow world with hunter hoffman, dave patterson, tom ferness, the folks at the hit lab, um, and uh, snow world’s kind of this iconic, um, most, most people in vr, maybe I’ve heard of it, but, um, yeah, it’s, it’s sort of the iconic, um, vr pain relief application.

Speaker 3:          It’s also the, the really forwarded the use of, uh, of vr in healthcare, um, and it’s being used with patients from a, with burn patients from the military and from kids and all different contexts. Um, some of the data that I’ll show is snow world data, but so this is lieutenant sam brown and uh, he came back from Afghanistan. He was severely burned and these are patIents whose, you know, 70 percent of their body is third degree burns. I’m the trauma, a blast blast traumas, etc. So these, these are really very, very patients and safe doses of narcotics can’t get them through all of their procedures. So they’re doing, they’re changing their bandages every day. They’re doing skin stretching, they’re doing skin grafts and all of these things. And it’s the worst kind of pain that’s out there. So, uh, you know, patients who are going through this have three problems, pain, just one anxiety and helplessness, and we know that, uh, your experience of pain changes dramatically when you feel anxiety and, and that loss of agency and it sure it changes that experience from just being paid to suffering. And so that’s kind the, the transformation that we wanted to change. Um, and this is a quick video. It does have some audio. I hope it goes through.

Speaker 3:          Oops, sorry. I tried to give you sound. That’s what happens when you try to make things better in the world with technology. Some I’ll tell you about the dinosaurs. Oh my god, that was, that was a nightmare. I’m okay. But anyway, so I’m just, oops, let’s see. This is what happens. Try to make things better and it gets worse. But, um, so what, uh, I’ll just kind of skip through this because I’m, I don’t want to take a lot of times. So basically what I think is interesting, uh, you know, since you guys do know a lot about vr, uh, so number one, uh, we, uh, number one it works and that’s really big. I mean, for patients like this, it’s, it’s giving them a lot of benefit. Uh, number two, uh, this is not a head mounted display. Actually, this is the optics off of a $35,000 helmet and a. Oops. Oh my god. What happened? Oh, we’re having trauma. Okay. What happened?

Speaker 2:          Sleep.

Speaker 3:          Oh, it went to sleep. That wasn’t my, it wasn’t my fault. I feel vindicated. I’ll still tell you about the dinosaurs, but I’m a. No, it’s still there. I swear this is always bringing hand puppets. This is what I learned. Sock puppets when you were the pc, ran into the problems and needs to restart. Okay. Anybody here from microsoft? My, my machine. I was doing demos out there and then decided to do an update. I have no idea. I. Okay. Okay. This is why we have hand puppets and I’ll tell you about the dinosaurs. So I was, this is, um, this is, I’m going off script here while this does this, but, so I was in, um, the, a bunch of our, um, my colleagues and otHer fellow students at the university of Washington, we went to Japan and it did this thing called the smithsonian to soar.

Speaker 3:          And they actually, the smithsonian museum gave us permission to use the name. Um, something’s happening here. Uh, bill gates has now infiltrated my, my thing. Okay. Uh, I don’t know. Anyway, so what happened was we went to, um, we went to hiroshima. So I used to live in Japan. I lived in Japan for seven years and um, I was the only one who could actually speak japanese, which was also funny because they, we got there and this guy said, okay, we want. So the whole thing was about dinosaurs, right? So we made this thing where you walk into the smithsonian and there’s this, this taranda don, and it’s a skeleton and you touch the skeleton and it comes to life when you grab the leg and then it lifts you up into, uh, into the sky and takes you to the land of the dinosaurs and you take pictures and then you come back.

Speaker 3:          And this was in the 19 nineties and it was crazy because we had a, um, I, I don’t know what this is doing here. Um, uh, for some reason eVeRythinG, everything has, everything has gone to hell. But uh, so this is, um, but, but this will, this will make you feel better because not. This was absolutely the epitome of, of bad technology experiences. So we got to hiroshima. We’re in the middle of hiroshima and, and in, in the convention center we set up a silicon graphics. We had like a half of a half a million dollars of equipment and we got everything set up and we had spent a week at the university. They’re a building this stuff. And um, anyway, we set everything up and they said, okay, now we’re going to turn the electricity off and we’re like, you’re going to turn the electricity off these machines, you know, you didn’t, you didn’t, you never turned them off once you turn them on.

Speaker 3:          So we’re like, you can’t turn this off. Well they said, well, this half of the room is on generators and this half is on electricity. Were like, we want to be on that half. And they just didn’t, they didn’t let us. So what? They said, okay, you can come in at 8:00. And then what they did was they turned on the generators and it sent a power surge through our, our computers and it completely fried the, the cord was, the cable was broken and it was, it was a complete nightmare. So we’re standing there and then all the press shows up because the americans are here with the smithsonian thing, with the dinosaurs and, and it’s going to be really great. And we’re like, oh my god, we got to fix this stuff. And we had to html in our, in our c code. It was really a mess. So that is, it could go on. But, um, anyway, the other, the other cool thing was I got to be the dinosaur and I, my, I to be the japanese dinosaur which goes something like this.

Speaker 3:          She was, she could easily come up. That means grab my leg, know I’m saving you some of it, but I’m going to take you to my world. So, um, this is the kind of thing you get to do when you’re a grad student at the university of Washington. Um, so we’re gonna we’re gonna. Hopefully get back into it. Uh, that was the sock puppet. That was the moral equivalent of a sock puppet. Um, and so I’m just going to jump ahead here to the cool thing, the brain pictures. Uh, this is another tip that I always give everybody a, there’s a psychological study that if you’re going to do any powerpoint presentation, it is way more convincing if you have a picture of a brain someplace in the studies. So they did the exact same powerpoint and then one had a picture of a brain and the other didn’t.

Speaker 3:          And the, and the one with the brain was way more convincing, so I always put a picture of the brain into every powerpoint you do. Um, so this is a data about snow world. So this is what happens in your brain, my brain, our brains, our collective brains with vr and without vr, uh, when we’re subjected to pain and stress. So there’s what’s called the pain matrix, which is these five areas of your brain, of our brains have brains that are activated when we’re under pain and stress. And three of them, the insula, the thalamus, the acc. I’m a, I won’t get into all of these, the neuroscience of it. But what’s cool is that you see with no vr, um, that these areas are really, really active. And that with vr, you see two really great things. One is that those, that pain matrix becomes a lot quieter.

Speaker 3:          So the brain activity is actually moving to other parts of your brain. And that is um, the, uh, the pacc, uh, the areas that are associated with cognition, with cool stuff. So this is a great picture that corroborates the self report about pain. And we can see that there’s actually something very deep happening in our brains when we use vr. Um, and that’s really great. Um, another study with, with vr, this was a within subjects, uh, fmrs, uh, so they actually built a hunter, built a $150,000 optical hmd, um, to go into an mri machine and um, uh, that, that, that’s a feat unto itself. But they did a couple of studies. This one compared, uh, the use, the, the outcomes with a within subject, within a patient within the same patient, a no treatment opioids, opioids plus vr. I’m just going to look at that, a relationship.

Speaker 3:          So, uh, this is comparing vr and opioids to the no treatment control. So a pain unpleasantness. Um, how bad was it? Uh, so, uh, the, a rating of pain, unpleasantness, so negative and this in this case is, is better. So, uh, the opioids reduce that, that feeling of pain unpleasantness. Sixteen percent and the vr was 38 percent. So we’re doing better than the drugs time thinking about pain, aka catastrophizing. Um, uh, we’re still doing way better than the opioids and everybody’s favorite. The amount of fun. I just love the image of like them going, okay, how much fun are you having in there? Um, while we’re inducing pain, uh, so vr is doing way better than the opioids. And what I think is really interesting is that the opioids are worse than the no treatment control. So that feeling that you get from opioids is actually worse.

Speaker 3:          People, people like that less than actually just enduring the pain without it. Uh, and I think that speaks to something about, about how we can, um, you know, people just don’t want to take drugs. They’re looking for, they’re looking for alternatives. so at least in this case, in this study we can be, we can say that the vr work better than the drugs. So we build applicaTions. One is cool, it’s out there. A cool is sort of a next generation snow world. I’m moving through a, I’m moving through a landscape. We’re playing paintball with otters. It’s designed to be really, really simple. Uh, one of the problems is that a patients who are undergoing these procedures, number one, they’re constrained a lot in their limits. They’re limited in their motion, but they’re also constrained because mentally they’re there, a lot of them are taking drugs, a lot of them are stressed out, they’ve got that anxiety, they’ve got the, you know, the loss of agency, all that problem.

Speaker 3:          So we want to make everything nonthreatening. Uh, it’s designed to be a runs for about 35 minutes. Um, we have patients, some of them, the longest ones that are kind of in an, a, in there for an hour, some are a lot shorter, but, um, they generally try to keep those procedures down to a minimum so people can tolerate them. Um, but, uh, so this is a study of cool, excuse me, I’m done at, uh, the pain consultants of east tend to see ted jones a neuropathic pain. So this is looking at chronic pain. what’s really interesting, a lot of things. Number one, 94 percent of the people actually got a benefit, which is huge. I’m 92 percent said they had a benefit after they took the helmet off. Um, and then if you look at the times they did two sessions, they did two different studies, one was five minute sessions, just a single five minute session, a pain reduction during vr, 60 percent, and then 33 percent after they took the helmet off.

Speaker 3:          and that lasted for hours and sometimes up two days later, um, the 20 a 20 minute sessions, three a series of 3:20 minute sessions, the pain reduction during vr was close to 70 percent, which is great because that shows that it’s not a novelty effect, it’s not just the newness of it. and actually we’ve, we’ve, what we see is that the more accustomed that people are to, uh, to using vr, the more benefit they get from it. So, um, we don’t think it’s just a novelty kind of thing and that the pain reduction afterwards was, was even greater up to about 50 percent and zero side effects. So, um, or close to it. Um, and this, this guy, he, uh, he actually was, I’m using opioids for quite a long time. He had very severe injuries from a desert storm. He finally got off of opioids and, and he talks about how opioids just, he never felt good and the vr makes them feel good when he does it.

Speaker 3:          So vr has a profound lasting effect. It’s not just a distraction. I’ll talk about this in a bit. Um, so we, we, uh, another application we have is called glow. It’s sort of a mUltilayered therapy, biofeedback. Um, we’re doing a lot of things at the same time. We’re doing biofeedback, we’re using a leap motion, so we’re getting small motor kinds of emotions were getting large motor kinds of rehab and then using biofeedback and skills development, helping people sort of at, at a number of different levels. I can talk about this application, but I’m, I’m going to try to try to keep going. Um, how am I doing here? Okay. We’ll get some more sock puppets. So this is what it looks like a sort of in, in the hospital context,

Speaker 1:          immersive really symbol in the house asleep.

Speaker 3:          Okay. So that, that kind of gives you an idea that’s um, so bedside postsurgery I’m also being used of course during procedures and then for chronic pain in chronic pain clinics, uh, different kinds of environments. Uh, we, we have really focused on hospitals and clinics rather than. I’m trying to take it to people’s homes. We have done some of that, but it’s really just, it’s a lot of work and it’s very difficult to the population that, that, you know, has the biggest health are the biggest pain problem of course is older folks. And um, uh, that presents a whole bunch of challenges. Uh, we did do a very interesting implementation with providence cancer center and this is also older folks. So we do see that that older people can, um, you know, the older set can enjoy vr and, and we all probably have some experiences of that.

Speaker 3:          But, um, so this was pancreatic cancer patients. Pancreatic cancer generally affects people who are 65 and older, um, posts invasive surgery. There were 29 patients, uh, they use cooling glow, a bedside kind of in that way. That was in that video, a 30 percent reduction in pain. So this is comparison to historic data. What happens to a standard of care, so 30 percent better than the standard of care, which is drugs and 20 percent reduction in the use and the need for those drugs and a strong trend to reduce the cost of care. And so we’re, we’re doing some followup studies with them. We’re working with rehab medicine, uh, and, and lots of stuff going on. Uh, this is, uh, a video of shorten them if I think I’m just going to skip over it, but if you look at our website, we’re firsthand, firsthand.com. this is a really great video.

Speaker 3:          Uh, he’s a really serious pain doctor. He’s not, he didn’t, he’s not a technologist, he’s not an oh wow. I really want to get a whole bunch of technology in my, in my practice. Um, he’s the head of pain medicine for, for Oregon, for the, at least in the northern region. So, um, and he, uh, he has seen the value and he really believes it. So, um, that I highly recommend this video. I’m just going to skip over it. These are some of the places that we’re working with. I’m going to skip over that. I want to talk some about design. And so the framework, the mechanisms, um, vr approaches to change personal experience. Uh, thiS is, some of thIs is borrowed from my friend giuseppe riva, who I highly recommend you check out his stuff. He’s great. He’s at the christian university in milan.

Speaker 3:          Um, uh, so the, the, the things that you can do with vr, you can structure a change, personal experiences, use vr to structure it with goals, rules, feedback. You can enhance personal experience sort of with multimodal experiences and kind of add, add another dimension, or you can replace it with synthetic experiences. Um, this is very quick, but this is a, this is the model. This is called the, uh, the, the neuro matrix. Uh, it’s melzack and wall melzack is a kind of famous in the, in the, um, in the pain world. Uh, but this is, this is the more I think about this model, the more useful it is. And what it is, is that. So on the left side we’ve got kind of inputs when you think about inputs, it’s inputs from our body and from, from the outside world, we’ve got sensory signals, we’ve got emotions and we’ve got cognition and these, all that.

Speaker 3:          What’s cool about this is we used to think of pain as soMething that we experience, like you step on a tack and that you’re gonna, you know, that signal’s going to go to your brain. We now know that your brain mediates all of our experiences. And so we take this cognition and our emotion and then we have outputs a sort of in a lot of that’s internal. We’ve got pain. Perception is an internal output. We’ve got our actions that we do take in the world and we’ve got our own stress regulation of how we handle stress. And so this is actually a cycle. It’s not, it doesn’t just move one side to the other. But this is, this is sort of an underlying model, and I’m not going to go into this in great detail, but I do recommend that you kind of check it out.

Speaker 3:          Um, and it overlays with sort of our model for how vr works. Vr has five superpowers. That’s the way I think about it. It’s immersive, it’s interactive, it is a psycHophysical experience, it’s cognitive, and it also hits us at an emotional level. Um, immersion is where things start. If you’re, if you’re not immersed and you’re not getting it, going back to tom furnaces, a head mounted display, that’s where performance and everything changes. So immersion is where it started, but it’s not where it ends and that’s that idea that we want to try to activate people and get them interactive. um, on the therapeutic side, a immersion gives you this opportunity for self-regulation down, downregulation, emotion control, all of those things. Uh, and that’s good for pain. It’s good for mental health. Uh, it’s also good for learning because we know how experts learn versus how novices learn.

Speaker 3:          I’m so active creative, uh, studies using snow world, for example, comparing it to passive media and some with our, our newer applications have shown that, that it’s much more effective. That interaction is, is a big component to the effect, um, oops. And a sensory learning body, body map changes our perception of ourselves. So we’re not thinking about, we’re not necessarily, we lose that attachment to thinking about my sore shoulder when I’m in cool and I just start doing it. So you see people, uh, people self limit, we self limit all the time, uh, and especially in healthcare and especially in, in our, our physical motion, uh, when you have an injury. So, uh, that manipulation of the body map, um, mental strategies, resilience. So we’re not just trying to immerse them for four slash seven, we’re trying to build some skills and motivation, positive psychology, and there’s a correlation between emotion and chronic pain and stress and the way we handle stress.

Speaker 3:          So on the therapeutic side, those are therapeutic strategies to leverage the superpowers of vr. And on the therapeutic side, a downregulation self regulation, emotional regulation, a patient engagement and patient activation. All doctors want their patients to be a lot more activated, a rehab, kinesiophobia, neurological DisorderS, things that we can directly address with the psychophysical phenomenon. Um, and mindfulness skills, habits, knowledge comes from cognition and that stress, depressioN, the inflammation. I’m alice static load if people are into the health side of things, uh, and catharsis the need to actually just go then and all of that. A do you woke up? Okay. Designing vr health experience. this is why. So I wanted to take you through the old model. So the old model, uh, we’ve all seen this, the old model evoke sensation, but it doesn’t enhance performance and the new model, uh, I just use a car, but basically you’re also building the road in vr.

Speaker 3:          It’s not just building the dashboard, but we’re also building a, the all everything about where they’re going. Um, so I went to do a little design thinking thing here and uh, and to use an example that, that I found really I’m a illustrative and also pretty moving. Um, so we want to create transformative exPeriences. If you’re familiar with design thinking, um, this is infiltrated a lot of different kinds of businesses and all of that. Uh, basically it has four steps. This is from ideo and stanford, the founders of, of the design thinking sort of paradigm, gather information, generate ideas, make them tangible, share the story. Uh, won’t really spend much time on that, but, uh, so this is a story that I heard on this american life and I was in my car and I, it, it just really hit me, number one is because I lived in Japan and it’s, it’s a story about Japan.

Speaker 3:          It’s called cause they know Denmark, which is roughly translates to the telephone of the wind. Um, so the story goes like this. So this guy, he taught us a hockey, uh, he lives in [inaudible], which is up in the north side of, uh, of honshu and he’s 70. And what happened was his, um, his, uh, uh, a relative, I think it was his nephew died and so he was feeling all this grief and he wanted to find a way to express that. So he, um, you know, it was in the design sense, he was sort of trying to gather information about his own feelings. He was doing this internally a instead of somebody else designing it for him. But that’s makes this even better, I think. So what he did was he went out and he got a, um, a phone booth and he got an old phone booth and he stuck it out in his yard and he put it out in the garden and uh, then he put a phone in it and he would go out to his garden and he would pick up the phone and he would talk to his dead relative.

Speaker 3:          And this is, I mean, this is, it’s very powerful, but it’s amazing, you know, he picks up a phone. Clearly it’s an old phone, it’s not attached to anything. Uh, but going through that motion and picking up this thing and having a discussion about this with his relative was cathartic for him and he felt better and relieved. Um, now fast forward, oh, suchi was hit by the tsunami in 2011 and it looked like this and this. So his, uh, sasaki sons, his, his, uh, his phone booth predates this. But after the, after the tsunami, people started showing up in his yard and a 10,000 people came from all over Japan and went into this phone booth. Now, why would you go across the country to go into this phone booth? There’s a whole interesting ritual to it, but I think if you go back to, um, if you go back to what, uh, if you look at this space, the space is very intentional.

Speaker 3:          There’s nothing there that you don’t need. It has affordances and sort of, um, uh, the way that the phone has, you know, it has a certain interaction built into it. It’s very familiar, but, um, you can sort of feel the environment, you can feel that you can sort of smell the grass behind it and um, and all of that. And I think it’s really interesting what is there and what isn’t there. It doesn’t tell you to do anything. You’re just walk in and you do it. So people were showing up and they were doing this. And I think, you know, in terms of, uh, of, you know, thinking about this as a designer, I think of it as sort of the anatomy of a transformative experience. Um, it starts with a meaningful place. So there’s rituals, there’s artifacts, there’s, it’s, there’s the sensory component. And it’s very intentional.

Speaker 3:          Um, the second piece is there’s a meaningful action and it’s self driven. It’s important to the person who’s doing it. And so, uh, uh, and it’s satisfying in some way they come out of it change. Uh, the third thing is it’s very personal, so you have to allow space. And I think the one thing that I see in a lot of, of virtual worlds is they don’t allow a lot of space. There’s not a lot of space for me to bring my own dialogue because the designers or whoever is so worried about, you know, they’re, they’re giving me their dialogue. But if we’re really going to embrace the power of the technology, which puts the human, the human at the center, we have to give the human the chance to be human and, and do their own thing. So allowing space I think is really crucial.

Speaker 3:          It’s appropriate and it’s also a spontaneous that, that they can, they can bring their own stories there. And, and the designer didn’t try to put all the stories there for them. This american life, I completely recommend this. It’s called one last thing before I go, oh, that was heavy. But, um, I think it’s a really great illustration of what good design is. I want to give you, I’m back to the virtual world. I want to give you some examples of the design process that we’ve done in different applications that we built. Uh, this one is called attack of the smu tens. Uh, we got an obscene amount of money from the national institute of health to build a museum exhibit and effect and see how effective it was for changing kids’ behavior. Uh, and it was, it was awesome. We built this, uh, 1800 square foot exhibit a.

Speaker 3:          This is our character, her name is tisha. We did tremendous research with the university of Washington dental school and all of that. So the first thing I just wanted to share some of this, so this was building a character and, and trying to, if you, if any of you have worked on building characters and really tried to make them effective, you know, how much work it is. So we had a, we had a sketch artist sitting down with kids and saying, what do you think dan, tisha looks like, and so we had the cave girl than tisha and the hardcore didn’t tisha and the nerd than tisha. And then we came across the sort of steam punk, amelia earhart, uh, we think of her as Indiana jones, the babysitter, so she’s cool, but she’s also kind of, we wanted her to, via sort of a certain thing and a role model.

Speaker 3:          So then the interesting thing was we took, we took that and it’s a real process to take those sketches and turn them into a three d, a three d character that also retains those characteristics that you want. So the interesting thing was we took, um, you know, we, we showed these to people, we showed them with, um, I think we showed them with different bodies with the same bodies. We changed the head slightly and people would go literally there, these kids would go like, ah, she’s stupid. Or like they literally said she’s hot. I would do her. And unlike your 10, this is, this is a picture, you’re 10, but you know, you’ve hit something. Um, I was also at nih and they asked me very, very bluntly, they said, what about the breast size? So I’ll just tell you that what we found was really, it’s very interesting if you look at feminist literature too, you see that, that people, we wanted a character that embodied health and we wanted it.

Speaker 3:          We wanted her to look like a normal person, not like lara croft. And so we intentionally made her a. We intentionally made her proportions, right, um, for a healthy person. And people didn’t respond well to that. And they, they did two things. One is they, they didn’t really, it wasn’t as likable, but they also made a, in their minds, they, we asked them how old do you think this person is? And so that they, they would, um, they would consistently say they were much younger. They would see that, that sort of body shape as being young. So we subsequently, we want to make her, um, you know, appealing. So we changed the proportions and tried to stay within the realm of what we thought was healthy, but, um, there was a certain point where, um, it, the, the thing about sort of the feminist literature prior to this, that there’s this correlation, this sort of dynamic that’s difficult because of attractiveness versus I’m sort of respectability or likability and the character and particularly for female characters.

Speaker 3:          So you’re working against all of these sort of social forces and you’re trying to move them in some way. And what we decided was, you know, we, we really believe that we want to change the, the, the way that women are portrayed in these kinds of, of things, but, but there’s also a backdrop of people’s expectations. So we decided not to fight that too hard. Um, but, uh, so what we did was we, yeah, we changed the faces and, and all of that. And we ended up with, within tisha, we also created this environment which was her lab and we wanted her to be this kind of inventive person a, this is what she ended up doing. So it’s, she would make these crazy things out of a, that’s her trans fractal resonator that’s made out of a vacuum cleaner in a, an old tv and, and the, the, um, the spoon thing.

Speaker 3:          I don’t know what that does and an umbrella, but, but she ends up going inside of her mouth. Um, here’s a quick, uh, a quick video of it and uh, it doesn’t have any sound, but. So what I was going to just, I think what I wanted to PoinT out waS, so we have a character, we have someboDy that she can relate to. There’s a cut scene. This is really about trying to. What we’re doing is we’re feeding sugar to bacteria and they poop out, acid. Kids love that and that. And so this is how we develop this kind of. It’s driven by, it’s driven by the, by the players. Everybody kind of gets the same experience. But what we did was we had a five person theater. We hacked a bunch of remotes. There’s a big projection, a, they had a stereoscopic glasses and all that.

Speaker 3:          But um, uh, so the idea was to use the sort of social context of a museum to allow people to kind of have interactions and say, oh, go get the floor. I’d go get the, you know, it’s, it’s pooping out acid so that they are internalizing some of these same kind of concepts. And, and um, we, it was gratifying to hear things like kids would come out of it and go, well yeah, I knew it was education, but it was still fun. And then they’d say it made me want to brush better. So we were trying to really drive home that it’s not about brushing longer, but it’s about brushing better and doing a better job. So we felt like that kind of reaction and that kind of outcome was really, uh, it really showed that there was a change in how people perceive the, the problem.

Speaker 3:          Um, so vr for behavioral and public health. So that was a public health initiative. Uh, um, just some points, uh, definitely, uh, try to apply a proven chain change model with proven measures. Try to, if you’re going to do this, go get existing measures that are already validated to validate what you’re doing, grab attention and then do something with it. Do something important with it. Build relevant and meaningful context and what you do. promote transformation through meaningful personal actions. So always put the user at the center and combine the intrinsic and extrinsic rewards because we know that intrinsic rewards are more powerful and lasting. Um, this is a quick view of, of a lot of the mental health stuff that we’ve done. We did a, this is called irac world. We did work with the department of defense. Um, so these were soldiers coming back from Iraq, dealing with ptsd.

Speaker 3:          Uh, this was quite awhile ago. Uh, but they’re going through a generic iraqi city, uh, and feeling that, uh, you know, feeling like they’re there. This is spider world, which we developed with, with hunter. Again, a arachnophobia, so direct triggers. Um, and this is another one from our friends over at in valencia, a christina botella. They’re using it for, um, eating disorders. Just separate your eva’s doing some of this work to uh, so this is rebalancing and recalibrating people’s expectations about, um, uh, sort of how the world works. Uh, eating disorders are an internal kind of imbalance between, uh, you know, if I eat that hamburger, I think I’m going to gain 25 pounds. Well, tHat’s physically impossible. So let’s try to recalibrate those expectations with the, with the outcomes, um, and make people healthier. Um, so mental health, uh, embodied therapy simulations, sort of the three genres of, of mental health simulations, phobias with specific specific triggers and realigning distorted sense of self or reality.

Speaker 3:          Um, so the takeaways and then I’ve talked to enough. Um, and I would love to get your feedback. So vr as a medium to enhance performance. Uh, there’s a strong, there is strong evidence of vr can reduce the biggest pain problems and reduce the need for drugs. It’s a powerful way to activate people to improve health, build skills, and promote habits and to design great vr health experiences. A start with an understanding of the need. I’m really based on a solid therapeutic model if you can and involve your target folks early and often that is a. I can talk about the benefits for the stakeholders, but basically I think the final thing is that we really want to change people after they take the helmet off. Um, it’s one thing to give people a great vr experience, but it’s really much more powerful if you’re, if you’re enabling them to do something in their real life, like get off of drugs or learn really cool things. Um, and that’s what I have to share. Thank you so much.

Speaker 2:          Thanks.

Speaker 3:          Do you want to work? It does work.

Speaker 2:          I think for a few questions for howard,

Speaker 3:          uh,

Speaker 2:          I can speak while I lived in the clinical world and I’m not familiar with some of the research that you were pointing out there. I’m kind of curious when we look at pain management and study after study, the two particular areas that seem to work the best as far as controlling, especially chronic pain, are cognitive behavioral therapy and physical activity. So I’m kind of wondering what your, your car, were there any research items that compared the vr and the activity that happens in the vr versus just the similar activities without the vr? Um,

Speaker 3:          well, uh, okay. So in a few things, are there specific studies that look at having them play paintball with otters in the real world? No, but, uh, I think that, you know, we have done, you know, we’ve been part of studies that have looked at other types of typical distractions or engagements, nurses chatting dvds, a tuesday, a two d games, lots of different kinds of things in. So comparisons to that show, the vr is more effective. Uh, one of the challenges of cognitiVe behavioRal therapy is that it’s very time consuming, um, and that it has a high, in a way a high patient burden. Um, and so what I think vr does really well is reduces that patient burden. So instead of, if you look at cognitive behavioral therapy, different than pain, but it’s very similar in posttraumatic stress, um, that a lot of people just don’t want to engage with it.

Speaker 3:          They don’t want to engage with their, they don’t want to sit around and say, I have ptsd or I have a mental health problem, or I have a problem to begin with. and so, uh, vr kind of transforms that talk therapy into action therapy and it’s kinda the same thing with pain. So instead of me sitting around and somebody’s telling me, well, just, you know, don’t think about it or cognitively get myself out of it. They, they have an experience. They, they see that they can move, they see, you know, that self limitation, the kinesiophobia and all of that. Um, they get over that and then that opens the opportunity for the chronic pain doctor to say, let’s think about that. You weren’t feeling pain there, you were actually moving, you are moving your neck in this way and we can show you that, um, let’s think about what that means. And then so they build off of that. I don’t think that we’re replacing the therapists. I think we’re enhancing their ability to deliver therapy.

Speaker 1:          Thinking about setting up, do you think you need to have, how was it like 30 days?

Speaker 3:          Yeah. Um, so everybody talks about the dose effect. Uh, that was a sort of a new term for me when I started working with nih. They’re like, what’s the dose? What’s the dose of a game? Um, I think the, so, so some benchmarks. Uh, we have, um, a doctor named adrian hamburger who was a at yale new haven sPine clinic, uh, he started using it for biofeedback for his patients. He said, well, I can get reimbursed for 15 minutes sessions, so guess what? I’m going to do 15 minute sessions. And uh, he’s just started using it with his patients and after three or four weeks that he, he had patients coming back and saying, doc, I’m not using drugs anymore. And he’s like, whoa, I didn’t reallY expect that. And, and you know, I, I think it’s amazing. It’s wonderful. So what we find is that in some ways, you know, if you look at that study that I showed you of a ted jones and all of this stuff is on our website and I can share more of the data, but, um, that sometimes it’s really surprising how powerful it can be for people that it might not take as long as we sort of think.

Speaker 3:          So if you’re trying to take somebody through a procedure at a hospital, it’s as long as the procedure goes, right. But If, when you talk about sort of mindfulness and biofeedback, there’s, how long does it take us to adopt those things and you know, doctors are using it for the chronic pain. Patients are using it for sort of 15 minute sessions. That’s pretty typical and they’re getting benefits from first session. But it does compound. Yeah, we, we, we don’t tell them you’ve got to do it this way. Um, but we do see that they, you know, once, once a week, twice a week, they’re getting that kind of benefit. And it’s not just a yale new haven that’s a san mateo and lots of other other hospitals too.

Speaker 2:          Pain is no longer there, but has there been any research done into that where I know they’ve done a thing with therapy to retrained and branding on there?

Speaker 3:          So the ramachandran is the sort of big name in mirror therapy and phantom limb a. Yeah, on the phenomenon is, uh, you know, basically clenching spasms was sort of where it started. So if You’re missing a hand, uh, you, you feel as if that, that hand that’s not there is always clenching. And so using a mirror to, um, to visually fool the brain. What’s cool about that is that I, I’ve talked to people who have, who have done a lot of that kind of therapy and that it works instantly, like if it works. And so I would say, uh, what they say is that if it needs to work on a healthy person, so even if you don’t have, have your hand, uh, if you take your hand away, that you get that physical sensation. So you can tell that you don’t have to be an amputee to, to know if it’s working.

Speaker 3:          One of the challenges with vrp will happen doing that. People have been trying, uh, they haven’t really crackeD that nut. Um, and it’s sort of a deeper topic, but I think there’s a, one of the challenges is not to get technical aboUt it, but one of the challenges is, is where’s the location? The mirrors out there and your hands are out there. If you put a camera on the head, it doesn’t work because of the angle. And so there’s a whole bunch of reasons why I think that contributing factors to it. I think there are some solutions to it which, uh, we, we may or may not work on, but phantom limb is a great example of how our brains are really taking a big role in, in that sort of pain cycle. Uh, and if you can change the way the brain is working, uh, and, and do some plasticity and those, those benefits do last with, um, with the mirror therapy. So, um, yeah, it’s a kind of a bigger topic. epic

Speaker 2:          is a commercial for the demo to us.

Speaker 3:          Um, yeah. Uh, so I, I can spend some time doing some demos out there and there’s another, another system out there we do not really because of what I said, you know, we’re, we’re really focused on hospitals and clinics and it’s just another thing to support people at home. If people have vr headsets, um, you know, we can, we can send you a demo or something. But uh, uh, I’ve got cards here. You can, you can send me information if it’s not a lot of work for us and we can just, if you’ve got a, if you’ve got a system at home then, then that’s much easier to deal with. But like, yeah, I don’t want to be dealing with grandmothers. I’ve done a lot of that and it’s hard.

Speaker 2:          My grandmother would love to.

Speaker 3:          I want to meet your grandmother

Speaker 2:          in terms of the longevity of these effects in the long term physIcal changes in the brain.

Speaker 3:          Yeah, that’s a great question. I think that my answer would be, so we do have mri studies, fmri studies are really hard to do, especially with vr, but you know, it’s, you know, it’s just people just hate going into mri machines too. So, um, it’s hard to do that kind of thing really and get accurate brain scans. But I think what, when you see people, so we do have a lot of suggestion that it works and we do want to promote neuroplasticity is an awesome book that’s called the brain that changes itself, which I highly recommend, uh, which, um, has some sort of vr components to it. but, uh, the, I think the indication is really does the pain stop me? You can see the manifestation. It’s good that the change has to be happening somewhere, right? I mean, it’s got to be happening inside the person.

Speaker 3:          Um, and you know, would you see that in the, in the voxels on your, on your mri? I don’t know, but you can say that, that there are significant changes when their response to pain changes and we know that, you know, you can look at it at other kinds of mental health studies and other health interventions that if you get a lasting effect, it’s gotta be, it’s gotta be held in the brain, right, or, or in the body, but it’s got to be held somewhere. So, I mean, that’s sort of a tautology, but if you are seeing a change, then the changes there,

Speaker 2:          what’s the next step? What’s the next generation?

Speaker 3:          I’m the next generation is adoption. And the biggest challenge that I face every day is, you know, I started out in a world where I had to tell people what vr was, um, you know, we’ve moved from the realm of science fiction to something that most people are familiar with. So now my conversations used to take a long time with, with doctors and they’d go, what is this vr stuff anyway? Uh, and then it was like, we’ve heard about vr, uh, can you tell us how it works in healthcare? And then it’s like, we’ve heard about vr in healthcare, but we’ve never done it and we don’t know what it’s like. So, and then my process with a hospital is, you know, this happened with provenance. They called me, I went up there, I, I showed it to him and then they go, okay, we get it, we see the data, we try it, we get it.

Speaker 3:          And then can you come back and actually see it with a patient? Um, and then, okay, now it’s with a patient, now will we believe it? And now we’re going to try a pilot. So those steps, thankfully those, those steps have become easier. But still, I think the big, the big challenge is we can build, like I’ve got a thousand ideas of things that I’m going to build when I can, but we just can’t keep building it and hope they come. So we need to bring healthcare along. And healthcare is, you know, I, I talk about healthcare is, is diametrically opposed to technology technologists. I live in, you know, silicon valley. Not proud of that. But, uh, I live in silicon valley and it’s like everybody loves disruption. I just want to disrupt stuff, just give us something, we’ll disrupt it. And healthcare is tradition based and those two worlds often collide.

Speaker 3:          And digital health is where that collision is happening. So I think that, um, this, in order for this to really achieve its benefit in, in the next step, I think it’s both adoption protocols, standardization, people believe it, uh, the, the, the tipping point, just so you know, the tipping point and in healthcare tends to be about 30 percent when a, when an innovation hits 30 percent, then everybody will adopt it because they don’t want to be behind their competition. We’re nowhere near the thIrty percent, but we’re well past the early adopters. And so what we need to do is to drive as hard as that tipping.

Speaker 4:          Right.

Speaker 3:          Okay. Two questions. Have you ventured into the neuro atypical?

Speaker 3:          Um, we do have, we have a psychiatrist or name is a and maloney. She’s working with a, um, a lot of those patients, a lot of whatever those people, a lot of people who are on the spectrum have a social cognitive problems, so they, the inhibition control emotion, uh, they get overwhelmed and she’s using it with a kids who get overwhelmed and like lock themselves in the, in the bathroom because they can’t deal with the world. So, um, this vr experience actually gives the parent, in that case, they can talk through the door and they say, okay, imagine you’re in glow and you’re gathering fireflies and you’re okay, let’s relax. And it, it actually gives them a dialogue to have that conversation much the way a therapist a kind of work changes when you introduce vr, it doesn’t get rid of the therapist and enhances the therapist’s ability to, uh, to do and administer their therapy.

Speaker 2:          Do you use the feedback from the range of motion for patients in recovery?

Speaker 3:          Right? Um, so that’s, that’s, uh, that’s something we, we do do. We do monitor it. We do gather a bunch of data. Um, the question is what you do with a, in a, in rehab, you want to give people enough data but not too much data and a lot of, um, uh, yes, we do gather data. Yes, we do show it to people. Um, there’s a lot of potential to do more there. I think that as people use vr and become more aware of it, uh, we, we, in addition to, um, I should’ve said this in addition to like the motion data, we gather a sensor data. So we’re using, um, got it here somewhere. Oh yeah. So this is a, this is a heart rate sensor, uh, just for the technology people in the world. This is a, um, this is by a company called squash.

Speaker 3:          There’s only two heart rate sensors out there that actually will stream the data scotia’s one. um, the mayo is another, but this one is really cool. So if you’re going to try to build something with, uh, with heart rate sensor, I would recommend that. Um, so the best thing actually is to get multiple streams. So we’ve done a lot of work with biosensors, with eeg and around heart rate and all that, and so to get not just the motion data, but to get the biosensor data and correlate that because then you can make some real judgments and ultimately we’re working on a system to modulate the experience, so increase the intensity and change, changing the dynamics and all sorts of, uh, of cognitive levels and, and, and modulating it in real time. So it’s not just a measuring what you’re doing, but it’s actually changing in real time to increase your, uh, your recovery and, and do better therapy. Um, maybe timewise. That’s what we have time for. Thank you so much.

Speaker 2:          Going to be around. Thanks.

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